Acknowledgement of Financial Responsibility and Privacy Practices Form For patients covered by insurance:I hereby acknowledge that and allow Wake Family Eye Care to file my insurance and accept payment from the insurance company. By signing this I also authorize the release of any health care information required by the insurance company to fully process any claims. I understand that any service not covered by my insurance will be my responsibility to pay. I understand that any applicable copays and coinsurance set forth by my insurance company are expected to be paid at the time of service. Patient's Full Name as Signature:Date of Signature: For patients not covered by insurance:I hereby acknowledge that applicable fees and charges are expected at the time of service unless prior arrangements have been made. Patient's Full Name as Signature:Date of Signature: Notice of Privacy PracticesEffective June 2, 2014 Wake Family Eye Care is required by law not to disclose or release any protected health information (PHI) without my written consent or the written consent of a parent or legal guardian. If you would like a paper copy of our privacy practices, please ask the front desk staff. A copy can also be obtained from our website: www.wakefamilyeyecare.com I hereby acknowledge that I have read and understand Wake Family Eye Care’s privacy practice policies. Patient's Full Name as Signature:Date of Signature:CommentsThis field is for validation purposes and should be left unchanged.